Healthcare Provider Details

I. General information

NPI: 1316018559
Provider Name (Legal Business Name): CYNTHIA S. WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 PLEASANT ROW NW
HUNTSVILLE AL
35816-2537
US

IV. Provider business mailing address

PO BOX 18488
HUNTSVILLE AL
35804-8488
US

V. Phone/Fax

Practice location:
  • Phone: 256-533-6311
  • Fax:
Mailing address:
  • Phone: 256-534-8659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberLNO2274
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: